Basic Information
| Provider Information | |||||||||
| NPI: | 1780637355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAKEW | ||||||||
| FirstName: | ELIAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15905 WILLIS WAY | ||||||||
| Address2: | |||||||||
| City: | WOODBINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217977521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104892821 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7300 VAN DUSEN RD | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207079266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017254300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/26/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | D0053055 | MD | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 413046400 | 05 | MD | MEDICAID | P00430518 | 01 | MD | RAILROAD | OTHER | 089000601 | 05 | MD | MEDICAID |